INCIDENT DETAILS

DESCRIBE INCIDENT IN DETAIL

ENTER APPLICABLE IMAGES OF INCIDENT
PROPERTY DAMAGE

IS THE INCIDENT LOCATION FREE OF PROPERTY DAMAGE?

ENTER IMAGES OF PROPERTY DAMAGE
MEDICAL/INJURIES

WERE THERE ANY EMPLOYEE INJURIES?

NAME OF EMPLOYEE INJURED

DESCRIBE INJURY IN DETAIL

ENTER IMAGES OF INJURY

CHECK ALL THAT APPLY BELOW

911 NOTIFED

FIRST AID RENDERED

HOSPITAL NOTIFIED

ENTER HOSPITAL NAME

DESCRIBE ANY MEDICAL ASSISTANCE RENDERED AT INCIDENT LOCATION

IF INJURED EMPLOYEE REFUSES MEDICAL ATTENTION, HAVE THEM SIGN HERE
REVIEW AND SIGNATURE
EMPLOYEE COMPLETING REPORT SIGNATURE
SUPERVISOR SIGNATURE
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.